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Wednesday, 28 November 2012
Page: 10097


Senator RYAN (Victoria) (16:33): I present the report of the Finance and Public Administration References Committee on Medicare funding for hyperbaric oxygen treatment, together with the Hansard record of proceedings and documents presented to the committee.

Ordered that the report be printed.

Senator RYAN: I move:

That the Senate take note of the report.

Earlier this month a change to the Medicare Benefits Schedule came into effect that removed Medicare funding for hyperbaric oxygen treatment of non-diabetic ulcers. That may sound obscure to people listening today. In fact it is only for a few hundred people annually in Australia. But if you are one of the people who suffers from non-diabetic ulceration, this treatment has been shown to be of particular benefit for when months and months of very expensive nursing care have failed. No-one disagrees with the concept that we should seek value for money for the money we spend on health care.

No-one seeks to challenge the cost-effectiveness analyses that underlie the assessment of new medical procedures and particularly the assessment of new medications. But in this case the process has broken down. We were presented with submission after submission, many confidential, many from providers of the services and of course from the Medical Services Advisory Committee and the Department of Health, but also, importantly, from the architect of Medicare, Professor John Deeble.

Hyperbaric treatment for various conditions has been on the Medicare Benefits Schedule since its inception in 1984. Medicare funding for hyperbaric oxygen treatment for non-diabetic ulcers is a more recent innovation. It has been effectively on probationary funding for well over a decade now. The reason it was put in in such a fashion was that there was not much evidence for this particular procedure upon it being added to the Medicare Benefits Schedule. But before anyone jumps to the conclusion about how services are funded on the Medicare Benefits Schedule, let me remind them that the overwhelming majority of medical procedures in this country have never had a cost-effectiveness treatment. We do this for new procedures now and we do this for new medications now, but there are many procedures and many treatments for conditions that are on the Medicare Benefits Schedule for which no cost-effectiveness analysis has been undertaken.

They were attempting to collect the evidence for this particular procedure to show whether or not it did in fact save the Commonwealth money, whether it was cost-effective and how effective it was in clinical use for people with these chronic ulcers which often lead to amputations because there is simply no way to treat them. Can I also say that ulcers that are being treated in this fashion are immensely painful for sufferers. Can you imagine having a wound that needs daily or every second daily treatment, an open wound on your leg or foot for months, in some cases years, on end. It has a massive impact not only on quality of life but on your ability to participate in the economy as well.

The troubling aspect of this was that a couple of things occurred at the Senate committee hearing. In particular we seemed to manage to resolve a conflict between the proponents of this treatment and the department of health about how they had measured whether or not it was effective.

A system that requires a Senate committee hearing to get the two people to actually agree on how we got to this point means that this process has not worked effectively.

There was debate over whether or not the Medical Services Advisory Committee was considering this as first-line or second-line treatment. The proponents of this care thought they had been assessed as first line, and from reading the documents it seemed that was possible. But when we read the documents in more detail and we had the benefit of an explanation, it became clear that it was appropriately assessed as a second-line treatment. But the proponents of this treatment had never benefited from that interaction with the Department of Health and Ageing or the Medical Services Advisory Committee. They had never had the opportunity to put the questions and have them answered in the way that our committee did. That is a breakdown in the system.

This committee report points out and our second recommendation is that consideration should be given to an independent review mechanism for MSAC decisions in the same way it is now undertaken for PBAC decisions for pharmaceutical benefits. I want to clarify that that review does not overturn a PBAC decision. We are not advocating an appeal mechanism for MSAC decisions; we are simply saying that the review mechanism for the PBAC, which allows an independent person to come in, look at the evidence and send a report back to the originating committee for reconsideration, is a good idea. It probably would have prevented this issue coming before the Senate.

There was some concern about the evidence used in order to make the judgement that this was not cost effective. I want to say two things here. We are in the middle of the design of a trial as well as the collection of data for a trial that will assess whether or not this treatment is cost effective and whether it should stay on the Medicare Benefits Schedule. No witness who came before us said that that assessment should not be undertaken. It seems perverse that we would take this off the Medicare Benefits Schedule pending the collection of that data, even though we know that taking it off the Medicare Benefits Schedule will actually prevent the collection of that data. If this regulation is not reconsidered by the government, we will not be able to see whether or not this particular treatment is effective, because people will not be able to access the treatment supported by Medicare. That is, to me, a circular argument.

I would also note that the data used to assert that this was not cost effective was remarkably small. It was a randomly controlled trial in the 1990s. Though it did meet the standards set by MSAC, it was of only 16 people. In the complex world of health economics, in order to understand whether or not a treatment is cost effective and clinically effective, a trial of only 16 people does not really give you the data you need. In this case, the Medical Services Advisory Committee did not take into account other data.

I am not a clinician, nor am I a medical expert, but, if we have a service that has been on the Medicare Benefits Schedule for a couple of decades, if we have the data being collected, if the proponents of the service, the patients, and the department of health are having disagreements about when it should have been collected and we are only dealing with a tiny population in another couple of years, it seems to me perverse to try to take a stand on principle and take it off the Medicare Benefits Schedule now. And the reason for that goes to an old saying in health economics, which is that the absence of evidence is not evidence of absence.

I say that because in health economics—which is a bit of a dark art; it is a very complex area dealing with a lot of uncertain information—just because we do not have any evidence to prove something is effective does not mean that we can assert that it is not effective. In the world of assessing new medical treatments and new pharmaceutical benefits, this is a critical thing to keep in mind. If we assert, mistakenly, that we do not have the evidence to prove it is cost effective and therefore we will deny treatment, we could be denying to people for years a treatment that we find out three or four years later is very clinically effective and cost effective. In this case it may also prevent us determining whether it is cost effective, because we will not be able to collect the data. I say again that the overwhelming majority of money we spend through the Medicare Benefits Schedule has never been assessed on a cost-effectiveness basis.

These points were made by Professor John Deeble, the architect of Medicare—a man I think every Australian actually owes something to, not just for their health care but also for saving them tens of billions of dollars over the years. I had the privilege of spending some time with him and having a conversation with him. I would suggest that the report is short, but his submission is even shorter—and I would suggest that people who are interested in this would actually benefit from reading his submission, which is on the committee's website.

I finish by saying that we are simply recommending that the government reinstate this treatment to allow the collection of the data so that in about two years time a true assessment can be made on a trial of more than 16 people and so that, in the meantime, people who are desperate for pain relief and some hope that their condition can be treated—absent an extraordinary intervention like an amputation—can continue to be given that hope.

I would like to thank the committee secretariat who, as always, assisted dramatically. We as senators have the privilege of getting across topics in a very short time and delving into them more deeply than in the other place. We do that with the assistance of an extraordinary secretariat—Christine McDonald and John, who have helped us immensely.

I hope the government takes this report in the way it is intended. We would not want to establish a precedent whereby things can be taken off the Medicare Benefits Schedule just because we do not have the data. I fear that would lead to a lot more popular and a lot more significant treatments being removed that have never been given that assessment. It is not grounds enough to deny people treatments which have, in some cases, been there for decades. That was a point made by Professor John Deeble, and it one the majority of the committee sticks with.